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2 Nov 2019 
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Nurses have various roles in the health care system ranging from being a caregiver, patient advocate, decision maker, counsellor, and communicator to mention a few (Hoffman, A. J. & Scott. L., 2003). Nursing in itself is a very stressful job due to various factors such as the workload, emotional stress of caring for the ill, working hours, working environment and the support systems and professional conflicts (McVicar, A., 2003). Critical care nurses are specialized to care for critically ill patients who are often at the verge of death. Maslach and Jackson (1981) identified the 3 main components associated with burnout as emotional exhaustion, depersonalization and diminished personal accomplishment. From the care aspect, “Studies have shown that approximately 20% of patient deaths occur during or shortly after an intensive care unit (ICU) admission.” (Swetz and Mansel.,2013). In most situations the discussions with patients in ICU regarding their wishes about their end of life care plan and treatment are rarely possible and prior wishes are often not known because of the suddenness and severity of their illness (Hofmann et al. 1997). As a patient advocate, inability to participate in the planning of the end of life care for their critically ill patients under their care, causes much stress and feelings of lack of professional empowerment for the critical care nurses.
The purpose of the study is to determine the relationship between the quality of end-of-life care and nursing burnout in critical care areas. If a relationship can be found between the quality or futility of end of life care and nursing burnout, changes can be made to empower the nurses through education, end-of-life training, counselling, ethical debriefing and change in existing unit policies (Browning, A.M.,2013).
Identification and conceptual definitions of key concepts
In this study, the dependent variable is the nursing burnout and independent variable is the quality of end of life care. These variables are naturally occurring and are measurable.
For the purpose of this study, the predictor for quality of end of life care will be the effective or need based appropriate care given to individuals who are near their end of life(WHO).The goal of the care given to patients in Intensive Care Units should be individualized and based on patient’s values, beliefs and meaning of life when they are the most vulnerable and can rarely speak (Drazen J.M.,2003). An indicator for the effective /quality care during the end stage of an individual is
For the purpose of this study, the quality of end of life care was operationalized as developing a structured system for delivering patient care that should improve the quality of life for the patient and the family as a whole by preventing and relieving the suffering ( Cook, D. & Rocker,G., 2014.)This quality can be achieved by early identification, assessment and treatment of pain and other problems: physical, psychosocial, and spiritual(WHO,2008–2012 & Palliative Care National Consensus project.,2004–2012). The care should include the involvement of patient and family members in planning care that reduces the stress in delivering adequate care in a patient centred care model. Clear communication is the major factor in determining patient and family satisfaction with end-of-life care (Heyland D.K., Dodek P., Rocker G., et al.2006).
For the purpose of this study, Burnout syndrome (BOS) has been defined as the experience of long-term exhaustion and diminished interest, usually in work context (Elshaera
N.S.M., Moustafaa M.S.A., Marwa W.A., Alexandria I.E.R.,2018). It occurs when individuals spend too much effort at work without having much time to recover from the stress ((Embriaco, N., Papazian, L., N. Kentish-Barnes, F. Pochard and E. Azoulay.,2007).
For the purpose of this study, Burnout in critical care nurses can be operationalized as, nursing burnout is the result of numerous factors in the work area relating to stress being a nurse advocate trying to meet the individualized wishes and care goal of the patient, inadequate support systems ,working under time pressure to mention a few(Cynthia P.,2007).The possible reasons for burnout in nurses working in critical care areas are that, they often face a great deal of stress and emotional challenges during their work with patients through the long duration of life support and intense treatment & care that nurse may perceive as non-beneficial to patients (Meltzer and Loucine.,2004).
If a relationship can be found between the nurses’ involvement in providing patient-centered, good quality end of life care and their burnout, changes can be made to empower the nurses through education, end-of-life training, counselling, ethical debriefing and change in existing unit policies (Browning, A.M.,2013)
Relational Statement
Providing effective, patient centered, and individualized quality end of life care to patients in critical care areas can influence the incidence rates of burnout syndrome in critical care nurses.
Literature search strategy
The CINHAL and Nursing & Allied Health Databases were used to locate research articles that discussed the relationship between quality of end of life care and nursing burnout in Intensive care units. The focus of the search was limited to English, peer- reviewed, full-text articles and scholarly journals within an adult population. A time limit or time interval was placed on the search for articles between 2010 & 2018 as there were numerous articles before that time period. The terms used for search in both databases mentioned above were,” End of life care”, “Nursing burnout”, “Intensive care units” and “Quality care”. Both the databases used smart text searching to provide the desired articles. In addition, the AND Boolean operator was utilized in both databases to assure the review of all relevant articles.
Rationale for selection of articles included in the review
In CINHAL, the search term “quality of end of life care” generated 249 results, “nursing burnout” generated 137 results. Search with” Intensive care units” gave 773 results. In order to identify the articles that contained all of the key identified concepts, the search terms “Quality of end of life care”, “nursing burnout” and “intensive care units” were combined using the AND Boolean operator, which generated 73 results. Again, combining the given search terms using the
AND Boolean operator and adding “Quality care” gave 48 results.
In the Nursing & Allied Health Database, all the search terms were combined using the AND Boolean operator which generated 54 results. The research articles were chosen based on how relevant the articles were to the research problem, the study purpose and the key concepts. The selected articles provided the relevant knowledge base about the research problem and the key concepts. It also showed the existing knowledge gap regarding the relationship between quality of end of life care and nursing burnout in intensive care units.
Synthesis of relevant empirical literature
The concepts of stress, burnout and end of life care had been an area of interest of researchers and nurses for several decades (Jennings, BM.,2008). Based on the literature search, in spite of the relevance and interest of these concepts, the effects of nursing stress and burnout on patient safety, outcomes and quality care are not very well explained by evidence (Jennings, B, M., 2008). The articles below are chosen from the many articles reviewed, based on their significance to the key concepts and the relevance.
End of life decisions: Nurses perceptions, feelings and experiences. McMillen R.E., Intensive and Critical Care Nursing (2008)
In this study, the researcher used a descriptive, non-experimental method where in purposive sampling techniques were used for data collection. The study was done on a small sample group of 8 nurses in an ICU in North England with work experience ranging from 6 months to 20 years. Structured interview data collection technique was used. The questions were based on the role’s ICU nurse play in the end of life decisions and how their involvement affect their perception towards quality of care given during the final stages of their patients. After the data analysis the researcher found that the experience of the nurses played an important role in their end-of life decision making process. The more experience the nurses had, the more involved they were in the end of life decision making process of the patients. This gave them a feeling of professional fulfillment and satisfaction leading to less work stress and burnout and thus were able to provide a good quality end of life care. The author stresses that this study can be reproduced both nationally and internationally.
Moral distress and Psychological empowerment in critical care nurses caring for adults at end of life., Browning A.M., American Journal of Critical Care (2013)
In this study, the researcher used a cross-sectional exploratory survey design which reviewed the moral distress and burnout of critical care nurses providing end of life care and ways to reduce the distress. The samples for this study were 277 critical care nurses recruited from AACN’s e-mail newsletter list, who were varying in age and experience. A moral distress scale and psychological empowerment instrument were used. The study found that when the nurses became active team members in the end of life decision making process, this facilitated psychological empowerment and thus reduced the moral distress and burnout. Thus, the positive attitude of nurses in turn enhanced the quality of patient care outcomes.
Burnout Syndrome in Critical Care Nursing staff. Poncet, Taulic, Papazian et al., American Journal of Respiratory and Critical care Medicine. (2007)
In this study, the researcher used a descriptive model study with questionnaires sent out to 165 ICUs in different parts of France with a total sample size of 2525 ICU nurses. Data was gathered using Maslach burnout inventory. Based on the results, the study concluded that one third of intensive care nurses had severe burnout syndrome. The study points out the areas of improvement from the data analysis of the questionnaire. The researchers conclude that improving the work environment, participating in end of life decision making and involvement in ICU team discussions can reduce moral distress and burnout in critical care nurses.
All the above studies had all the key concepts addressed in the proposed study. The literature synthesis showed that all the studies were similar in the descriptive design used to gather data. The sample selection was similar in all the studies; critical care nurses taking care of patients in their end of life phase were the study samples. The study could be reproduced to larger groups. Even though the sample size and locations of the studies conducted varied, the studies concluded that there was a direct relationship between nursing burnout and critical care nurses’ involvement in end of life decision making process providing quality end of life care.
Strengths and limitations of the empirical literature
The common strength for all the 3 selected empirical literature was the use of descriptive design and collection of as much data from samples through interviews and questionnaires. The study findings and tools used could be easily reproduced into larger study groups. In addition, the researchers limited the exclusion criteria to reduce bias. As the study designs were descriptive, there were no threats to the validity of the studies. Another main strength identified was that all the studies had similar concluding findings and all the researchers involved provided suggestions to further improve the empowerment of nurses to prevent nursing burnout.
The limitations to the studies were the vast difference in age group and experience of the samples studied that gave some totally different answers to the tools used by the researchers. Even though literature search strategy should include all relevant articles available, only the articles in English were used for the studies.
Summary and conclusion
The synthesis of the Empirical literature reviewed, showed that further research is required in the field of critical care nursing burnout. Even though several studies are done to address the causes and effects of nursing burnout in general, there is no concrete evidence or supportive literature in the concepts of the relationship between how the good quality end-of-life care given to critically ill patients reduces the moral distress and eventual burnout in the critical care nurses. The researchers in the studies reviewed, also suggests that there is a major gap in the knowledge base in promoting professional empowerment and the supportive system development for intensive care nurses. (Gandi, et al.2011). These suggestions to help build positive working environments in all the 3 dimensions of burnout- emotional exhaustion, depersonalization and diminished personal accomplishment, will in turn promote quality care of patients under their care.